Wednesday, September 25, 2013

Know your dialysis: dialyzer type and needle gauge

Today, let us look at the last couple of things that are important about your dialysis.

Dialyzer type is a very important factor in determining whether you are getting good dialysis. As you know, this is akin to an artificial kidney where the actual filtering takes place. This is where the excess fluid and toxins are removed.

There are many types of dialyzers in the market today. The important thing to check is whether your dialyzer is low-flux, medium-flux or high-flux. High-flux dialyzers offer the best clearance among all variants followed by medium-flux and then low-flux.

The difference is the amount of surface area inside dialyzer available for the blood and the dialysate to interact. The greater the surface area, the better the clearance of toxins. High flux dialyzers have a greater surface area than medium and low flux dialyzers and therefore, are able to clear toxins much better than them.

High flux dialyzers are also able to remove more fluid easily compared to low flux dialyzer which have constraints in fluid removal. Though fluid removal is a setting on the machine, this is done by altering the Trans-membrane pressure (TMP) and low flux dialyzers cannot withstand a high TMP.

Clearance of middle molecules is something that everyone on dialysis must be worried about. Middle molecules do not have an immediate impact like potassium or sodium but over a long period of time, they can cause something called Carpal Tunnel Syndrome and other problems. So, it is important to make sure we are getting adequate clearance of middle molecules. The clearance of middle molecules is not at all satisfactory in low flux dialyzers. High flux dialyzers do very well in clearing middle molecules. However, dialysis duration plays a very important role in clearing middle molecules as well.

High flux dialyzers are unfortunately and expectedly, much more expensive than the low and medium flux dialyzers.

The gauge of needles is another important factor to consider while determining your dialysis prescription. Dialysis needles are thick! Who likes them? Thicker needles allow more blood to be removed from your vein than thinner needles, obviously. So, using a needle with a thicker diameter allows you to run your dialysis at a higher blood flow rate. Trying to run at high blood flow rates with a thin needle can cause your blood to hemolyze which can actually be fatal if not detected early. So, it is very important to choose the right type of needle with the right blood flow rate.

One thing to remember is needle gauges are reverse in order. The higher the gauge, the thinner the needle. 16 gauge is thinner than 15 gauge and 16 gauge is thicker than 17 gauge!

In India, most people use 16 gauge needles because we run at low blood flow rates compared to the US where most people use 15 gauge needles because they run at higher blood flow rates.

Your technician or nurse, totally devoid of ego and extremely well-versed with all these aspects of dialysis - some are so learned when it comes to dialysis, they actually have come up with a fascinating set of theories for different aspects like why the US runs at high blood flows - will generally make a good choice when it comes to which dialyzer and which needles would suit you rather than just use a default for all. However, it would do you a great deal of good if you discuss both these things with your nephrologist and arrive at a considered, well-thought out decision than just accept the default that is used for all!

Remember, medicine is highly individual. What works for one person will not necessarily work for all!

Tuesday, September 24, 2013

Know your dialysis: Blood flow rate and dialysate flow rate

As we saw in the last article of this series, the dialyzer has two compartments - the blood compartment and the dialyzer compartment. The blood flows through the blood compartment and a special fluid called the dialysate flows through the dialysate compartment. The dialysate is prepared by the dialysis machine by mixing three liquids - the acid solution, the bicarbonate solution and pure water in a certain proportion.

The most important part of our dialysis happens in this dialyzer. This is the artificial kidney which is performing the most important task the kidney performs - that of cleaning the blood of the excess toxins and water.

Since the cleaning happens in the dialyzer, it is important that more and more blood passes through the dialyzer from the body. There is a pump that pumps blood out of the body through the arterial needle. The faster the pump rotates, the greater the quantity of blood that is pumped through the dialyzer and the better the blood is cleaned.

Similarly, since the dialysate is the fluid that is surrounding the blood compartment, the volume of dialysate also impacts the amount of cleaning that happens. More dialysate means more toxins can be removed from the blood. The dialysate flow rate can also be controlled by the machine based on a setting.

If you are getting four hours of dialysis, thrice a week (and that is the bare minimum anyone with CKD on Maintenance hemodialysis must get!), the number of hours you are spending on the machine is limited to twelve per week. So, it is important for you to ensure that you get the best dialysis possible during those twelve hours. The blood flow rate and dialysate flow rate are by far the most important parameters that affect the cleaning of your blood of toxins. Ultrafiltration rate is not affected by these parameters at all. But the clearing of toxins is almost entirely dependent on these two parameters.

Generally, our extremely knowledgeable technicians and nurses who are totally committed to our well-being and would go to any extent to help us feel better, would be aware of all these finer nuances of dialysis. :-)

However, for those unlucky few patients who go to centers where they have clueless staff who will do everything possible to reduce their work and headaches, there could be a chance that your blood flow rate and dialysate flow rate is set to unreasonably low numbers. This is because low blood and dialysate flow rates means less chance of anything going wrong. Never mind if the clearance achieved is low. Never mind if this could spoil your quality of life and not allow you to feel your best. Never mind if this could actually reduce your lifespan!

One thing to be careful about is to make sure you don't go overboard with these changes since too high a blood flow rate could have some negative consequences as well. Make sure you discuss with your nephrologist before making any changes. The human body is very individualistic. Each one has its own quirks. What I have explained here are only general guidelines.

One thing is for sure though - the higher your blood and dialysate flow rate - the better your clearance!

Sunday, September 22, 2013

Know your dialysis: Conductivity

Yesterday, we saw how Ultrafiltration and dry weight are really important parameters to keep an eye on before your dialysis treatment. Today, let us look at another important parameter - conductivity.

Ever had to hear a scolding from your technician or nurse for coming back with too much fluid weight gain? All of us probably have! Now, guess what? Chances are that they are responsible for this! Seriously. Read on.

The conductivity setting in a dialysis machine controls how much Sodium is present in the dialysate. What is the dialysate?

A schematic representation of a dialyzer

Ok, let's get to some basics. I am sure you know that the dialyzer is the artificial kidney that does the actual work of cleaning our blood of the excess fluid and toxins. How does this actually happen? There are two compartments in the dialyzer - the blood compartment and the dialysate compartment. The blood flows through the blood compartment (what else did you expect?) which contains hundreds of 'hollow fibres' which are very thin pipe like structures which have many, many pores on their walls. All around these hollow fibres is the dialysate compartment through which a special solution flows. The excess fluid and the toxins flow through these pores from the blood compartment to the dialysate compartment.

A diagrammatic representation of how substances in solutions move from areas of high concentration (right in the picture above) to areas of low concentration.

Why doesn't the blood itself leak out of the pores? That's because the pores are very, very tiny and the size of the blood cells are larger than the size of the pores. The pores are designed so that only the toxins and water can pass through them.

Now, it is possible that things from the dialysate also pass through these pores and enter the blood. It all depends on the size of the substance and the concentration difference on the two sides of the pores. Any substance can only move from one side to the other if the concentration (the amount of the substance per unit volume) is more on one side than the other. If the concentrations are the same, no movement will happen.

Now coming back to Sodium. The dialysate must be ideally designed such that the concentration of Sodium in it is around the same as that of a healthy human body. This is around 135 to 145 mEq/liter. The dialysate, therefore must also be maintained around this level.

The dialysate is prepared by mixing three liquids inside the machine - the Acid solution (Part A), the Bicarbonate solution (Part B) and RO water in a certain proportion.

The conductivity setting of the dialysis machine directly corresponds to the level of sodium in the dialysate. A higher conductivity means a higher sodium level in the dialysate and vice versa. By altering the conductivity desired, we can tell the machine what sodium level we would like the blood to be exposed to. The machine does this by altering the proportion in which it mixes these three liquids.

As in anything related to dialysis, as indeed, in medicine, every individual is different and there is no one single number for conductivity that is suited to all. Generally, a high conductivity causes excess sodium to be present in the dialysate and as a direct consequence, in our blood while a lower conductivity cause lower amounts of sodium to be present in the dialysate and in our blood. Excess sodium causes excess thirst and causes us to drink more water while low sodium causes low blood pressure and cramps as well.

So, if you come back with excess fluid weight gain, it is quite likely that your conductivity setting was higher than you need it to be. Blame the techs or this! Not yourself!

But I am sure most of us are lucky enough that our technician or nurse knows all this and sets the conductivity that is suitable for our body. I am sure most of them understand the problems related to excess sodium and low sodium and most of us don't have to ever worry about this at all. Right? :-)

For the minority among us whose technician or nurse do not know about this, start with a conductivity of anything between 13.8 to 14 and then if you are getting cramps or low blood pressure, go up a point or two (0.1 or 0.2) at a time. If, on the other hand, you are feeling too thirsty and feel you can drink the water in all the rivers in the country and still not tire, try going down a notch at a time (0.1 o 0.2) and see how it feels! Always remember to discuss any changes you make with your nephrologist since he or she is the most aware of your overall condition. What is explained here is only a general guideline!

Remember, it YOUR health on the line. It is YOUR body that is being dialyzed. The least you can expect is that YOU be consulted on matters related to this. This will obviously make sense only when you are aware of these things.

Saturday, September 21, 2013

Know your dialysis: Ultrafiltration & Dry weight

For those of us lucky to be on dialysis, it is important to know some of the basic aspects of dialysis. As you know, the technicians and nurses looking after us during dialysis have so much time for individualized care and are so knowledgeable that we can completely trust our life in their able hands. They are totally devoid of ego and are so humble that they will listen to us if we tell them to set a particular parameter to some level. Right? :-)

So, coming to ultrafiltration. The lucky ones among us don't produce any urine. Yeah, think about it. No waiting in line for the loo during the interval of a film. Who wants to use those terribly unhygienic public loos? No pacing around impatiently on a long flight waiting for someone to come out. No need to take breaks during a long car journey. No bio-breaks during meetings. Yes, being anuric has its advantages!

When you're kidneys are not working as well as they should, they don't remove all the water you drink. Some or all of it stays inside your body. This water is partly in the blood, partly in the body's tissues and partly in between the tissues.

This has a number of undesirable side-effects - your blood volume goes up, your feet and hands may swell and you could also get breathless because the excess fluid could go and accumulate in your lungs. Not everyone will experience all these symptoms. Each one of us has his or her own favorites.

Dry weight is your body weight assuming there is not one drop of excess fluid that has not been removed by your kidneys. It is your weight assuming your kidneys were working. Now it is difficult to tell exactly what your dry weight is because your kidneys aren't working! So, that leaves it to our able and knowledgeable technicians and nurses to determine the dry weight!

Since there is extra fluid in your blood, the amount of blood your heart has to pump is not normal. The average human body has around 5 liters of blood. Even if you are one of the techs' favorite patients and are putting on a measly 2 liters between sessions, that's a whole 40% more volume for the heart to pump! This cannot be good. If you're more like me and want to make sure you're getting your money's worth on dialysis, you're likely putting on about 4-5 liters when you have a one day gap! That's a whopping 100% more! This is much worse!

Now, on dialysis, one of the most important things that happens is the removal of this excess fluid. So, you can drink again! The process of removing this excess fluid from your body by the dialysis machine is called ultrafiltration.

You can read here how the body is capable of letting go of fluid only at rates of 400 ml/hour or less.

So, if you are about 2 kg over your dry weight, you're removing fluid at 500 ml per hour - assuming you do four hours. If you're 4 kg over your dry weight, you would be removing fluid at 1 liter per hour. This is very dangerous for your body especially your heart.

So, it is very important for you to be aware of your dry weight, to know how you feel when your dry weight has gone up (because, maybe you've been eating well) or down (you've been exercising) and have complete control over how much water you are removing every session. Discuss your Ultrafiltration Goal (also called UF) with the person who is setting it and arrive at a number keeping all this in mind.

Remember - remove too much - and chances are that you could get a very low Blood Pressure and cramps; remove too little - and you will have fluid in your body when you get off - which means you cannot drink as much until you get your next session. What could be worse???

Sunday, September 15, 2013

The skewed importance of materialism in modern day Jain Dharm

Jain Dharm, or the Jain religion was historically an extremely non-materialistic religion. The desire for materialistic things was frowned upon. The only quest that was worth pursuing was that for moksh, or salvation - the freedom from the cycle of birth and death. Pure Jains went to the temple not to ask for material comforts - money, a good job, a good spouse, good health etc. In fact, the deities in the temples - the tirthankars, it is believed, cannot even give these things. They have already attained moksh showing us the path to it.

In recent times, however, many changes have crept into this religion. A lot of people have begun expecting material benefits from the religion. A religion that was totally anti-materialism is being used to promote materialism and this is really, really sad.

Take for example, the Mahavir Janm Vanchan day during the Paryushan Parv. On this day, there is this tradition of ghee boli. This is when representations of the fourteen dreams that Trishala Devi, the mother of Lord Mahavir had are bid for by the Jain Sangh. I will not go into the demerits of this here. You should visit this link where it is beautifully explained. What I want to highlight is the relative bids for the different dreams. Trishala Devi got fourteen dreams after conceiving the Lord. The fourth of these dreams was of Goddess Lakshmi. The bid for the fourth dreams surpasses all other bids. People bid for this dream many times more than the other dreams.

Isn't this entirely wrong? Isn't it obvious to all that people are bidding more for this dream in the hope that Goddess Lakshmi will bless them and get them more wealth? This is completely against the basic tenets of the dharm that Lord Mahavir propounded. It is completely against the very fundamental principles of the original dharm that Lord Mahavir and indeed, before him the other Tirthankars preached. And yet, year after year, the Jain Sangh continues this tradition in the garb of raising funds for the activities of the temple for the entire year. I say, STOP! Let us do less activities. Let us spend less. Let us not have so many swamivatsalyas or community lunches. It is better to do less than to do more by insulting our Tirthankars in this way.

The shameless 'pleasing' of Goddess Lakshmi continues even after the boli is completed. There is bidding for who will carry the her statue during the procession that is taken out after the Paryushan Parv is completed! People will request for the statue to be brought into their shops on the way of the procession. At every step, the Jain sangh is knowingly encouraging this blatant and completely wrong practice of giving Goddess Lakshmi more importance than the rest of the dreams.

The bid for Goddess Lakshmi is just one of the wrongs that is happening in the religion. There are multiple others like poojas and artis for devi-devtas, presenting 'navlakha haars' to devis, adorning the idols of the tirthankars with expensive ornaments, the list is endless! When did Jain dharm become such a showy and pompous religion? This was not what Lord Mahavir wanted!

I am really sorry to say, this entire exercise has the blessings of the Jain sadhu-sadhvis or the Jain clergy. They probably like to see high amounts being bid in their presence dropping hints that their presence has inspired the laity to bid increasingly high amounts! If the sadhu-sadhvis take a strong stance on this, it would be enough for this practice to be put to an end immediately. But will they? I would think not!

The only thing one should follow any ritual in Jain dharm for is moksh. Nothing else. Not more money, not to get rid of health problems, not to give birth to a child, not to ensure that your business does well. Practising Jain dharm for all these things is not only ineffective, it is totally wrong and I can say with a certain degree of certainty, that it is only making us attach bad karm to ourselves.

Some people argue that if we do not allow these changes to come in, Jains would turn to other religions to solve their material problems. I say, LET THEM! We should never compromise on the basic principles of our religion just so that people who do not understand it go elsewhere. What is happening, unfortunately, is that even people who understand the basic principles start indulging in this shameless quest for materialistic benefits from the religion.

What have we gained from this? What have we lost? These are two very fundamental questions every right thinking Jain must answer.

Friday, September 13, 2013

You have no choice but to be aware

For people that have kidney disease, in fact, any chronic condition, it is very important to be aware of the condition, the options available and the pros and cons of each. I see so many people on dialysis every day. Unfortunately, many of them rely on others to make their decisions. Some rely on their family, some rely on doctors, some rely on other patients with similar conditions. This is not good at all.

I would strongly advise you to read up as much as you can about your condition, become a member of an online group of people that has a similar condition and ask questions when you visit your doctor.

The internet is a great source of information. You should regularly look up your condition and keep abreast of what's happening in that field. Google Alerts are a great way to get a daily digest of the latest in any field right into your inbox! I have a Google alert set up on "dialysis" and "Atypical Hemolytic Uremic Syndrome" apart from other things. That way I am certain that the most important news on these subjects will always reach me in time. I also follow some nephrology blogs like those of Dr. Ajay Singh, Nephron Power and Renal Fellow Network among others. You should get a good RSS reader account like Feedly and subscribe to these blogs. This is a very easy way to keep up with the latest.

I have learnt some really important stuff simply by being part of online support groups. The simple fact of having dozens of others with similar problems like you can be heartening. Whenever I have a problem related to my home hemodialysis, I post it online and within hours, I get replies with how others have handled the same situation. Contrast this with having to wait for an appointment with my nephrologist and waiting to get his advice. Of course, you need to be judicious when you decide what questions are meant for a support group and what questions are only to be answered by a nephrologist. For example, a support group cannot help you decide which Blood Pressure medication you must take. However, a support group will definitely help you to feel better when you have just pulled off too much fluid on dialysis. And remember to contribute back to the group when you can! These days, there are many places where you have groups. Facebook also has groups for most things.

Some of us are lucky to have doctors who look beyond commercial factors while recommending treatments. Not all of us are that lucky. If you have a chronic condition, chances are that at some point in your life, you will run into doctors who ONLY look at the financial benefit they are getting while recommending something to you. Yes, the world is filled with cunts, right? But it is difficult to tell one from the other especially if your interaction is short. So, remember to ask questions.

"You need to get a fistula made for dialysis."

"Why do I need dialysis? What are the options within dialysis? What is the chance of success of a fistula surgery? Anything we can do to improve that? Who is the best fistula surgeon in town?"

You get the picture?

Ask questions. Understand your options. Understand the pros and the cons for each. Then make the decision along with your doctor. Never let the doctor decide everything. Remember, it is your life. You are the only one that will bear the consequences. Is it too much to expect that you be a part of the decisions?!

This is where education comes in as well. If you are well read about your condition and know the options, no one can take you for a ride. If you know nothing about it and rely completely on others, then no one can help you. The choice, really, is entirely yours.

Wednesday, September 11, 2013

Solving my hunger problem

First of all, sorry for not posting for such a long time! I was busy with religious rituals - the Jain 'Paryushan Parv'. Eight days of special rituals including the last day of fasting in some form.

Coming to today's post, I had a weird problem till some time back. I used to feel hungry all the time. I would have my breakfast at around 8:30 in the morning and would feel hungry by about 11 and I would need to have some snack. By 1 o'clock, I would feel hungry again. Lunch would happen then. By 4:30, I would get hungry again. I ended up snacking quite a lot. Most of these snacks would be unplanned and so, unhealthy!

Well, I could fix this by planning to have a snack every 3 hours and making it healthy. But then, doing that is not an easy task. Planning two snacks every day apart from your usual meals can be more difficult than you can imagine. And I am one hell of a fussy guy when it comes to food. I cannot eat the same things for more than one day at a time. If I snack on something one day, I need something else the next day!

Another problem was my reputation. My office has glass walls that are all see-through. Anything I do is visible to everyone. Taking out a box every couple of hours and eating is not at all good for your image. Believe me. At a previous company I worked for, I got told in an anonymous manner (in a Fishing Pond game) to give my mouth rest at least sometimes. And it was not from talking.

So, I had to find a way to control the frequent hunger pangs I was having.

I consulted the NephroPlus Chief Dietician, Akhila a couple of months back and told her about this problem. She suggested I maintain a food diary. I did so religiously for a week. She then studied it and suggested that I include more protein in every meal. Protein offers satiety and does not let you feel hungry too soon.

I started doing that. I consciously started including protein in my meals. It wasn't too difficult despite me being a vegetarian. Milk in the morning, dal in the afternoon and so on. This really helped. Whenever I manage to include adequate amount of proteins in my food, I find that I feel hungry much later.

This is good tip for those who feel hungry often. Include protein in your meals. Protein lasts much longer and hey, it also improves your albumin which is very important for your overall well-being and longevity!

Sunday, September 1, 2013

I wish I could wear a stethoscope

When I was a kid, I was very clear that I wanted to be an engineer. I did not want to have anything to do with medicine. I hated Biology and the thought of dissecting rats was not appealing. I did go on to become a Chemical Engineer in 1997.

Looking back, if there is one regret I have in life, it is not doing medicine. These days, I fantasize that I am a doctor, walking into a surgery wearing scrubs, a stethoscope around my neck, feeling the pulse of a patient and then going about the complicated procedure finally relieving the patient of his problems!

It must be so magical! Seriously! A doctor's work, to me, is unquestionably the most satisfying job that exists on the planet. When I met my classmate Anuj Kapadia, now a cardiologist, after many years, as a patient, I listened with amazement as he recounted his journey and how he spends time at the hospital from 6 in the morning till 10 or 11 in the night and then is sometimes called back for emergencies. Well, it seemed like a tough life. But his one statement after this summed it all up. "It feels nice!" Not many people can say that about their jobs!

The beauty of taking away problems related to health of a fellow human being can have no parallel. This can give you a kick like no drug can.

Even others in medicine, not only doctors, get a chance to experience some part of this satisfaction. Nurses and clinical technicians, for example. They get to do some of the stuff doctors would do and this can be great as well. Since not everyone gets to be a doctor, this could be a great alternative as well.

At NephroPlus, I do get a chance to watch all this from the periphery. But that is no substitute for the real thing. I think I am very clear in my mind. If I had to live my life again and were allowed one change among the decisions I have made, it would be my choice of career for sure. I would pick medicine without a doubt.